Research Paper Prevention & Cessation

Innovative call emerging from a qualitative study for workplace designated stop- area

Marie Chan Sun1, Lovena Rathoa2

ABSTRACT INTRODUCTION Designated smoking areas (DSAs) have become a common feature of public places in various developed and developing countries that have ratified the AFFILIATION World Health Organization (WHO) Framework Convention on 1 University of Mauritius, Réduit, (FCTC). However, this situation is not in line with the WHO FCTC. In this Mauritius 2 Université de Bordeaux, context, this study was designed to explore the perception of stakeholders on Bordeaux, France the DSA prevailing in workplaces in Mauritius and to explore the feasibility of smoking cessation interventions in the workplace. CORRESPONDENCE TO Marie Chan Sun. University of METHODS A qualitative study using semi-structured, face-to-face interviews was Mauritius, Réduit, Mauritius. conducted among the various stakeholders in tobacco control in Mauritius. Data E-mail: [email protected] collected were transcribed verbatim for analysis. KEYWORDS RESULTS Three main themes emerged from this study: 1) a need for comprehensive workplace smoking cessation interventions, smoke-free smoke-free law, 2) a need for smoking cessation services, and 3) a need for environment, qualitative study, stakeholders’ involvement (local government, employers, and health professionals) developing countries in the promotion of tobacco cessation programs. Received: 20 August 2019 CONCLUSIONS We make a call for a workplace Designated Stop Smoking Area (DSSA) Revised: 6 November 2019 in order to phase out existing DSAs. DSSAs will be a therapeutic means to divert Accepted: 3 December 2019 smokers away from DSAs, in order to change their behaviour with respect to tobacco use. Group therapy, individual counselling, and tobacco treatment will be made accessible in these DSSAs, which with a touch of innovation can become a VIP lounge for stop-smoking services. This innovative call for DSSAs is meant to sensitize policy makers of developing countries on how to proceed for the elimination of DSAs.

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INTRODUCTION free environments in all indoor public places, indoor Comprehensive smoke-free policy workplaces, on all means of public transport, and, as The World Health Organization Framework appropriate, other public places’. Convention on Tobacco Control (WHO FCTC) is an evidence-based health and legally-binding treaty Workplace designated smoking area that requires its 181 Parties to implement evidence- Article 8 also stipulates that the use of designated based measures to reduce tobacco use and exposure smoking areas (DSAs) does not provide effective to tobacco smoke1,2. Article 8 of the WHO FCTC refers protection3. Nonetheless, DSAs still exist in public to the need for protection from exposure to tobacco places in both developed and developing countries. smoke3. It emphasizes the need for ‘100% smoke- Indoor areas for smoking are mostly common in

Published by European Publishing on behalf of the European Network for Smoking and Tobacco Prevention (ENSP). © 2020 Chan Sun M. and Rathoa L. This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial 4.0 International License. 1 (http://creativecommons.org/licenses/by-nc/4.0) Research Paper Tobacco Prevention & Cessation

airports and are considered as ‘smoking lounges’ while 1948 Universal Declaration of Human Rights, Article DSAs exist in many workplaces4. This situation is not 1 states that ‘All human beings are born free and in line with the WHO FCTC because Article 8 of the equal in dignity and rights’14. Article 3 states that WHO FCTC highlights the need for a comprehensive ‘Everyone has the right to life, liberty and security for effective protection from secondhand of person’14. Article 25 of the same Declaration smoke. The FCTC does not recommend enclosed mentions ‘health as part of the right to an adequate areas for smoking in public places or workplaces5. standard of living’14. Internationally, the right to It is interesting to appraise the qualitative study health was first articulated in the 1946 Constitution by Burton et al.6 who revealed that smokers never of the World Health Organization15. The General smoked in indoor designated areas but preferred to Surgeon16 put forward that ‘Non-smokers have as go outdoors to prevent others from being exposed to much right to clean air and wholesome air as smokers tobacco smoke6. Another qualitative study by Bondy must have their so-called right to smoke, which I and Bercovitz7 highlighted the need for a complete would define as a right to pollute’. However, in the smoking ban on construction worksites, instead preamble of the WHO FCTC, the Parties expressed of making provisions for DSAs. On the other hand, their determination ‘to give priority to their right Sherriff and Coleman8 revealed employers’ belief to protect ’3. Also, the preamble to the that they would violate the rights of their employees Constitution of the WHO states that ‘the enjoyment if they did not allow them to smoke on the worksite. of the highest attainable standard of health is one of It has also been reported by Kaufman et al.4 that the fundamental rights of every human being without community members considered law enforcement as distinction of race, religion, political belief, economic a violation of smoker’s rights. or social condition’3. Concerning Article 12 of the 1966 International Workplace smoking cessation intervention Covenant on Economic, Social and Cultural Rights, The evaluation of the first smoking cessation workplace ‘it is the right of everyone to the enjoyment of the intervention in Hong Kong showed that smoking highest attainable standard of physical and mental cessation programs, chosen by smokers and supported health’ (WHO 2003)3. Considering the Convention by employers without further incentives, were feasible on the Elimination of All Forms of Discrimination in a busy working environment9. A pilot clinical against Women, adopted by the United Nations trial of smoking cessation services implemented in General Assembly on 18 December 1979, Parties will the workplace has demonstrated the feasibility and eliminate gender discrimination in the field of health efficacy of providing workplace smoking cessation care3. Focusing on the Rights of the Child, Parties to services10. A qualitative study exploring employees the Convention acknowledge ‘the right of the child who were involved in a workplace smoking cessation to the enjoyment of the highest attainable standard programme showed that contributors to quit success of health’3. were the workplace setting, quitting with colleagues, In 2017, on the occasion of the Human Rights competition and motivation, as well as group strategies Day, health was emphasized by the WHO Director- to resist smoking11. In Iowa, workplace smoking General as a fundamental human right, with good bans were nearly universal and two-thirds of the health being the resultant of other basic human workplaces offered activities to help employees quit rights including access to safe drinking water and smoking within the context of the Iowa Smokefree , nutritious foods, adequate housing, Air Act; there was practically no barrier to adoption education and safe working conditions1. The WHO and implementation of workplace smoking cessation Director-General, in 2017, stated: ‘The right to interventions12. health for all people means that everyone should have access to the health services they need, when Controversy on human rights of smokers vs and where they need them, without suffering non-smokers financial hardship…’. The central principle of the Graff13 confidently put forward the fact that ‘there 2030 Agenda for Sustainable Development is to is no constitutional right to smoke’. Referring to the ensure that no one is left behind.

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Justification for the study METHODS The Constitution of the Republic of Mauritius puts A qualitative approach was used to explore the views of forward the protection of one’s right to live in a representatives of the following stakeholders: Ministry healthy environment as follows: ‘Everyone shall have of Labour, Ministry of Environment, Ministry of Health, the right to an environment that is not harmful to their Business Process Outsourcing companies (BPOs), health or well-being’17. Considering the no-smoking Media, Trade Unions, Academia, and Non-Government policy in public places in Mauritius, which has been Organizations (NGOs). Stakeholders were identified by implemented since 2008–09, smoking is banned in a purposive sampling approach. Inclusion criteria were: all indoor public places including indoor workplaces adult, employed, literate, and consent. Participants unless a DSA is available18. Therefore, the island of were recruited until data saturation was reached. The Mauritius does not have a comprehensive smoking number of interviewees was eight. ban in workplaces. The International Tobacco Control Conducted as per the Declaration of Helsinki, (ITC) team highly recommended the elimination of this study obtained ethical clearance from the DSAs, emphasized as essential to protect non-smokers Ethics Committee of the Department of Medicine from exposure to and to provide a of the University of Mauritius. Every participant smoke-free environment for smokers to quit19. The was provided with a participant information sheet loopholes related to DSAs that exist in Mauritius, and and consent form. All subjects provided informed certain legislations in other countries, prevent non- consent before participation in the study. The semi- smokers to live in a 100% smoke-free environment. structured, face-to-face, individual interview was This situation prevails because of the standpoint conducted in the participant’s office where privacy of trade unions in Mauritius. However, it is not prevailed and the interviewee was comfortable in line with Article 8 of the FCTC3; it also does not and able to talk at ease. Data were collected using align with Article 3 of the Universal Declaration of an audio recorder in addition to note taking. The Human Rights that ‘Everyone has the right to life, duration for each interview was 20–30 minutes. liberty and security of person’14. At the local level, it The interview guide comprised open-ended is in contradiction with Chapter 2 of the Constitution semi-structured questions. Collected data were of the Republic of Mauritius that highlights transcribed verbatim. Thematic analysis, as the protection of one’s right to live in a healthy discussed by Braun and Clarke20, was the method environment as follows: ‘Everyone shall have the used for analyzing data collected and for identifying right to an environment that is not harmful to their patterns within coded data, to generate themes. health or well-being’17. DSAs in the workplace are Each transcript was read several times to familiarize controversial. Since the implementation of the non- ourselves with the transcribed data. Important comprehensive smoking ban in Mauritius, there has words or groups of words representing interesting been no study to explore the views of stakeholders features of the data were identified and highlighted on this issue of DSAs in workplaces. as initial codes. Relevant codes were gathered to In light of the controversial status of the smoke- form potential themes. By reviewing the themes, the free policy in Mauritius, this study was designed thematic map of the analysis was worked out. Fine- with the following objectives: 1) to explore the tuning to the naming of the themes was developed perception of stakeholders on the DSAs prevailing by the iterative ongoing process of analysis. Pertinent in workplaces in Mauritius, and 2) to explore the quotations from participants were selected in line feasibility of smoking cessation interventions in the with the research questions for the presentation in workplace. It is the first research that puts forward the report. Anonymity of participants was maintained the views of stakeholders on DSAs in workplaces in during data analysis and presentation of findings. Mauritius. The outcome of this study is the provision of the means for policy makers in Mauritius, and RESULTS other African countries, to address the gap in the Data analysis led to the emergence of four main implementation of comprehensive smoke-free themes, with each main theme having two to four policies. sub-themes, as shown in Table 1.

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Table 1. Main themes and sub-themes related to the Table 1 presents in a simplistic manner the themes perception of stakeholders generated. On the other hand, Figure 1 shows the findings of this qualitative study in a detailed manner. Theme Main themes Sub-themes Number Theme 1: Support for tobacco control policies 1 Support for tobacco Adoption of 100% smoke- The first theme has two sub-themes: strengthening control policies free environment the law by adopting a 100% smoke-free environment, Enforcement of tobacco and enforcement of the tobacco control policies. control policies 2 Actions for Sensitization of smokers Strengthening of the law by adopting 100% smoke-free implementation of stop- Identification of funding smoking services environment Provision of counselling Regarding that Mauritius does not have a and treatment comprehensive smoking ban in workplaces, Involvement of participants were in favour of strengthening the stakeholders current tobacco control policies in Mauritius that 3 Benefits of workplace Benefits to employees allow workplace DSAs. Participants put forward the stop-smoking services Benefits to the company need to address the existing loophole about workplace Benefits for the country DSAs to achieve a 100% smoking ban in workplaces. 4 Controversy on the Rights of smokers Stakeholders agreed that the WHO proposed an human rights of citizens Rights of non-smokers excellent initiative concerning the need for removal I have no right to smoke if of smoking areas in all workplaces. my smoking affects others ‘The elimination of tobacco smoke in all indoor

Designated smoking area in the workplace

Adoption of Enforcement of 100% smoke-free tobacco control policies Favorable Unfavorable

SUPPORT FOR TOBACCO CONTROL POLICIES

Health & safety reasons

RIGHTS OF RIGHTS OF SMOKERS NON-SMOKERS

Health information Support to quit smoking Personal choice to smoke [Sensitization of smokers]

WORKPLACE STOP Counselling & treatment SMOKING SERVICE by health professionals

Stakeholders Funding

BENEFITS TO EMPLOYEE/ Figure 1: Generation of themes from the views of participants on designated smoking area in workplaces. EMPLOYER/GOVERNMENT

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workplaces including private offices is an excellent Sensitization of smokers objective to be adopted by the WHO’. (1, M) Participants shared the view that smokers should be ‘It [WHO’s recommendation] is a good objective provided with assistance to quit smoking. There is a taken by the WHO…’. (2, M) need for smokers to have easy access to appropriate ‘I completely agree with the WHO and I think it is a treatment to combat tobacco dependence. There good measure to eliminate smoking all public is, thus, the need for sensitization campaigns places and indoor workplaces…’. (3, M) among employees to inform them about tobacco- ‘Being a non-smoker, I think that the WHO brought related diseases and to promote tobacco cessation. a very good idea which we [stakeholders] shall fully Sensitization needs to focus on the benefits of adopt in the future’. (4, M) smoking cessation. However, effective sensitization ‘The WHO is right as the FCTC doesn't imply the programs should be convincing, motivating, and existence of smoking areas’. (7, M) attractive, otherwise smokers would be reluctant to ‘I agree with the WHO for not recommending quit. There is a need for the stop-smoking services to smoking areas on work premises. Their [WHO] aim is be attractive and interactive. to help smokers to quit smoking’. (8, F) ‘Firstly, we should help them to stop this bad habit of smoking and educate them on which is Enforcement of current tobacco control policies associated with smoking...’. (4, M) Participants shared the view that enforcement of ‘We should give them information on how to stop current tobacco control policies should be addressed smoking because that person needs help as he or she is by implementing the existing penalties to non- addicted to ’. (6, F) compliant citizens. ‘A good initiative is to sensitize the smoker about the ‘Yes, indeed! Mauritius should implement stronger impact of on the health’. (8, F) laws if they want to eliminate this silent killer across ‘Instead of giving negative information, we should the island. Introducing more strict laws will also help inform them about the benefits of smoking cessation to decrease the number of people diagnosed with lung and at that moment the person will realize its cancer.’ (4, M) advantages’. (6, F) ‘Yes, Mauritius should reinforce the law for a healthier environment and increase security measures Identification of funding in terms of exposure to tobacco smoke’. (5, M) The workplace smoking cessation program was viewed ‘I suggest that the government follows what the in terms of resources such as finance, counselors, WHO had said and a further increase in tobacco and the time availability of employees. The cost- taxation is required. We have already started to effectiveness of smoking cessation programs was put implement stronger laws…’ (2, M) forward. ‘Mauritius needs to completely ban smoking in ‘…we need resources such as funds and manpower workplaces (…) If ever someone is caught smoking in (…) it is not easy to implement such programs because non-smoking areas, we should fine them so that they there are too many resources which are unavailable. will be discouraged to smoke’. (3, M) The medications are expensive …’. (7, M) ‘…smoking areas are strictly prohibited in hospitals, ‘…there will be lots of work in terms of money to do educational institutions and in sports and recreational health campaigns and volunteers to participate in this infrastructure. If these places have become smoke-free project’. (8, F) then we should extend the law into workplaces’. (6, F) Provision of counseling and treatment Theme 2: Actions for implementation of stop- In addition to educational support, smokers need to smoking services be provided with counseling and nicotine replacement The second theme had four sub-themes: sensitization therapy. of smokers, identification of funding, provision ‘In addition to information about smoking cessation, of counseling/treatment, and involvement of we should provide them with psychological and stakeholders. pharmacological treatment. We should provide them

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with all the necessary treatments to help them quit’. (6, Benefits to employees F) ‘As these smokers quit smoking, they will save money ‘I think that sensitization of all employees is essential and their health will start to improve …’. (6, F) and should provide them with alternatives for tobacco ‘If we go towards these people, it would be very such as nicotine gums to prevent carvings’. (2, M) beneficial to them. They would be more available to attend the programs (….). The programs should be Involvement of stakeholders flexible so that employees will not be absent from work All respondents agreed that both the government to follow this program’. (7, M) and employers should be responsible for organizing tobacco cessation programs with the help of health Benefits to the company professionals. ‘… start providing these types of programs to their ‘It would be amazing if the Ministry of Health could employees as it will lead to healthy people working in assign some health professionals or officers to inform the company and increase in its productivity’. (4, M) these people…’. (1, M) ‘…the productivity of the company is increased and It was put forward that employers should be there will be a decrease in absenteeism due to tobacco- involved in providing these programs. related diseases’. (6, F) ‘…actions should be taken from the Ministry of ‘…the time taken for the program must not be greater Health and the Civil Society. Health professionals than their time taken to smoke’. (2, M) especially doctors should be recruited to prescribe medical treatment and qualified counselors such as Benefits for the country health educators are needed to provide support to these ‘Reducing the prevalence of smokers is beneficial to people’. (7, M) the country’s economy as we reduce the import tobacco ‘… not only through the intervention of the Ministry products…’. (2, M) of Health but the company may also hire private health ‘…these people will stop polluting the environment… professionals to help his employees to quit smoking’. As we invest money in treatment, we will recover (6, M) it because the morbidity and mortality (…) will ‘Employers should also take action by introducing decrease’. (6, F) cessation programs and sensitize the employees (…) the employers may organize committee forums whereby Theme 4: Controversy on the human rights of employees will benefit advice from governmental smokers and non-smokers organizations’. (3, M) Last but not least, the human rights of both smokers Participants underlined the importance of the and non-smokers were discussed. It was thought that company’s involvement in providing treatment for a complete smoking ban and removal of DSAs will tobacco dependence. prevent smokers from being free. However, it was ‘The company can also provide them with substitute also acknowledged that smoking is harmful to non- products which can help in stopping this ’. smokers and violates their right to live in a 100% (4, M) smoke-free environment. ‘Companies should contribute to the project but they ‘The availability of a dedicated space allows may not all be willing to share the costs’. (7, M) smokers to smoke freely without disturbing his/her colleagues’. (4, M) Theme 3: Benefits of workplace stop smoking ‘(…) if we really want to protect someone from services exposure to tobacco smoke, the environment should be Further data analysis revealed the emergence of sub- 100% smoke-free because it involves the human rights themes related to the benefits to employees, company, of the non-smokers’. (7, M) and country. Improvement of the health of employees, the enhanced reputation of the company, and benefits DISCUSSION to the economy of the country will be illustrated with We now discuss the four themes that emerged from the quotes of participants. this qualitative study in the following sub-sections:

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controversy on the human rights of citizens, need Need for smoking cessation services for smoking cessation services, benefits of workplace One of the four major themes emerging from this smoking cessation programs, and support for tobacco qualitative study was: actions for the implementation control policies. The outcome of the discussion leads of stop-smoking services. Referring to the us to put forward a solution to the issue of workplace contribution of stakeholders in tobacco cessation DSAs. programs, participants pointed out the role of three pillars, namely the government, employers, and health Controversy on the human rights of citizens professionals, in such programs. Health professionals In this study, participants perceived that smokers have need to be recruited by the Ministry of Health for a right to smoke, provided that they do not smoke workplace that includes smoking in restricted areas. Participants who had expressed cessation services. The findings of this study are in support for DSAs on work premises perceived that a line with the study among hospital staff in Egypt. comprehensive smoking ban will deprive smokers of Radwan et al.24 demonstrated the urgent need for their rights to freedom. This finding is in line with the provision of smoking cessation programs to both Sherriff and Coleman8 who revealed employers’ belief medical and administrative staff of hospitals (85.4%) about employees’ rights to smoke on the worksite and the provision of smoking cessation training and also with Kaufman et al.4 who reported the for physicians (84.8%). Another finding from this perception of community members about smoker’s qualitative study pertains to the view that employers rights. However, these views do not corroborate are to be involved in sensitization programs. This with Article 3 of the Universal Declaration of Human is also in line with Radwan et al.24 who highlighted Rights, which does not mention the ‘right to smoke’ the need for the establishment of a tobacco control (Graff13). committee in hospitals (81%) and the provision of Participants in this study referred to the right of logistical support for tobacco control programs and non-smokers to be free from exposure to tobacco policies (77%). smoke. This finding is in line with Katz21 who stated that failure to provide a smoke-free environment Benefits of workplace smoking cessation would transgress the individual’s right to lead a programs healthy life. The WHO put forward the role of Benefits for the country, highlighted by participants, reform to advance the right to are in line with various studies demonstrating cost health and to create an environment for people to benefits. The very recent mathematical modeling by live healthy lives22. Smoking is rather a personal Honeycutt et al.25 showed that the potential costs of choice than a human right. The choice of a person interventions were substantially larger than actual to start smoking is his or hers. Nonetheless, the costs. Benefits included savings in terms of medical personal choice of a smoker impedes the rights of costs in the range US 700–750 million and in terms non-smokers for unpolluted air, in line with the well- of life-years gained in$ the range of 21000 to 22000 known phrase ‘my liberty ends where yours begins’. years. More than a decade ago, Warner et al.26 had Quote Investigator on its website23 states that the shown that smoking cessation was a significant authoritative source of the origin of this quote economic investment for companies with long-term has not been found but considers Finch (1882) as benefits with a benefit-cost ratio of nearly 9 times. the one who stated: ‘Your right to swing your arm Benefits for employees include financial savings leaves off where my right not to have my nose struck and health improvement upon successful smoking begins’. From the same website23, we can read that cessation. Mache et al.27 showed that the intention Camp (1887) made the statement: ‘I have no right to quit smoking significantly increased over time to throw my arms out in a crowd, for I might hit with employees participating in smoking cessation somebody on the nose. My right stops where his nose intervention. Participants put forward that decreased begins. I have no right to drink if my drinking injures absenteeism and increased productivity as favorable others’. By extension, we will put forward: ‘I have no outcomes for the company providing smoking right to smoke if my smoking affects others’. cessation services. These views are supported by

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Halpern et al.28 who demonstrated that absenteeism in the workplace in Mauritius while maintaining DSAs was significantly higher among current smokers than during a period of one or two years with planned former smokers, with a significant decline with years phasing out of DSAs for comprehensive smoke- following smoking cessation. Productivity assessment free workplaces in Mauritius. The role of three by peers showed significantly higher values for former main stakeholders, the government, employers, and smokers than for current smokers. health professionals has been highlighted for the implementation of smoking cessation interventions Support for tobacco control policies in the workplace in Mauritius. Finally, this innovative Participants of this study expressed support for call for DSSAs is meant to sensitize policy makers the adoption of a 100% smoke-free workplace of developing countries on how to proceed for the environment, which shows that they are in favour elimination of DSA. of the removal of workplace DSAs. This is in line with the Article 8 of the WHO FCTC3, the Strengths and limitations recommendation made by the ITC19 for the removal This is the first qualitative study in Mauritius whereby of DSAs in workplaces, and the recommendation by the views of stakeholders were explored. However, Bondy and Bercovitz7 for a complete smoking ban the duration of interviews was limited in light of the on construction worksites7. Concerning the support busy schedule of the stakeholders. The number of for the adoption of a 100% smoke-free workplace participants was only eight, but it was verified that environment in Mauritius, there is a need for the saturation of data was reached. clause that allows the current existence of workplace DSAs to be removed from the law. We trust that the CONCLUSIONS removal of workplace DSAs needs to be undertaken Data generated from this qualitative study led to the in a planned phase-out manner with the provision of formulation of a new concept, the workplace DSSA, as supportive measures for smoking cessation services a solution to the workplace DSA, which still prevails in the workplace. in some countries despite the WHO emphasis on the The idea of a planned phase-out of workplace need for 100% smoke-free workplaces. This new DSAs with the provision of smoking cessation concept provides policy makers the means to address services now leads to a new concept: workplace the breach, constituted by DSA, in the implementation ‘Designated Stop Smoking Areas’ (DSSAs). A of comprehensive smoke-free policies. The new DSSA in the workplace is an area designated by workplace DSSA concept provides the means for employers to provide stop-smoking support to phasing out DSAs in developing countries where employees who smoke, resulting from a workplace there are DSA-related loopholes in their legislation. policy to gradually divert smokers away from a DSA The proposed workplace policy will also be useful to to DSSA for smoking cessation. Therapeutic means developed countries in their endeavour to achieve a will include motivational group therapy, dedicated comprehensive smoke-free environment. individual counselling, and tobacco treatment prescription by tobacco treatment specialists to be REFERENCES made available in DSSAs. The right to have access to 1. World Health Organization. Health is a fundamental human right. https://www.who.int/mediacentre/news/ smoking cessation services when and where smokers statements/fundamental-human-right/en. Published need them, as specified by the Director-General of December 10, 2017. Accessed March 25, 2019. the WHO1, justify the new concept of DSSA. Also, the 2. World Health Organization. World health statistics 2018: principle of leaving nobody behind lends support to monitoring health for the SDGs, sustainable development the provision of support to smokers having difficulty goals. World health statistics 2018. Geneva, Switzerland: to quit smoking. World Health Organization; https://www.who.int/gho/ Recommendations publications/world_health_statistics/2018/en/. Accessed March 25, 2019. This qualitative study led to a new concept: workplace 3. World Health Organization. Framework Convention on DSSA, which will help to address the issue of DSAs in Tobacco Control. Geneva, Switzerland: World Health the workplace. We recommend the creation of DSSAs Organization; 2003. https://www.who.int/fctc/text_

Tob. Prev. Cessation 2020;6(February):9 https://doi.org/10.18332/tpc/115032 8 Research Paper Tobacco Prevention & Cessation

download/en/. Accessed March 25, 2019. 15. World Health Organization. The Right to Health: Fact 4. Kaufman MR, Merritt AP, Rimbatmaja R, Cohen JE. Sheet No 31. Geneva, Switzerland: Office of the United ‘Excuse me, sir. Please don’t smoke here’. A qualitative Nations High Commissioner for Human Rights, World study of social enforcement of smoke-free policies in Health Organization; 2008. https://www.ohchr.org/ Indonesia. Plan. 2015;30(8):995-1002. Documents/Publications/Factsheet31.pdf. Accessed doi:10.1093/heapol/czu103 March 26, 2019. 5. World Health Organization. The WHO Framework 16. Office of the Surgeon General, Office on Smoking and Convention on Tobacco Control: 10 years of Health. The Health Consequences of Smoking: A Report implementation in the African Region. Geneva, of the Surgeon General. Atlanta, GA: Centers for Disease Switzerland: World Health Organization; 2015. https:// Control and Prevention (US); 2004. PMID:20669512. www.afro.who.int/publications/who-framework- 17. Republic of Mauritius. The Constitution. http://www. convention-tobacco-control-10-years-implementation- govmu.org/English/Legislations/Pages/Constitution. african-region. Accessed March 25, 2015. aspx. Accessed March 29, 2019. 6. Burton S, Hoek J, Nesbit P, Khan A. ‘Smoking is bad, it's not 18. World Health Organization. The Public Health Act: cool… yet I'm still doing it’: Cues for tobacco consumption Government Notice No. 263. Geneva, Switzerland: World in a ‘dark’ market. J Bus Res. 2015;68(10):2067-2074. Health Organization; 2008. https://www.who.int/fctc/ doi:10.1016/j.jbusres.2015.03.004 reporting/Annex2_Public_Health_Regulations_2008.pdf. 7. Bondy S, Bercovitz K. Non-smoking worksites in the Accessed March 29, 2019. residential construction sector: using an online forum 19. ITC Project. ITC Mauritius National Report - Results of to study perspectives and practices. Tob Control. the Wave 3 Survey. Ontario, Canada and Pamplemousses, 2011;20(3):189-195. doi:10.1136/tc.2010.038398 Mauritius: University of Waterloo and Mauritius Institute 8. Sherriff NS, Coleman L. Understanding the needs of of Health (MIH); 2012. https://itcproject.org/files/ITC_ smokers who work as routine and manual workers Mauritius_NR_W3-Oct19v27-web.pdf. Accessed March on building sites: results from a qualitative study 29, 2019. on workplace smoking cessation. Public Health. 20. Braun V, Clarke V. Using thematic analysis in psychology. 2013;127(2):125-133. doi:10.1016/j.puhe.2012.10.002 Qualitative research in psychology. 2006;3(2):77-101. 9. Wang MP, Suen YN, Li WHC, Lau OS, Lam TH, Chan doi:10.1191/1478088706qp063oa SSC. Proactive outreach smoking cessation program for 21. Katz JE. Individual rights advocacy in tobacco Chinese employees in China. Arch Environ Occup Health. control policies: an assessment and recommendation. 2018;73(2):67-78. doi:19338244.2017.1308309 Tob Control. 2005;14(suppl 2):pp.ii31-ii37. 10. Bold KW, Kimmel L, Hanrahan TH. A Pilot Clinical doi:10.1136/tc.2004.008060 Trial of Smoking Cessation Services Implemented 22. World Health Organization. Advancing the right to health: in the Workplace for Service Industry Employees. the vital role of law. Geneva, Switzerland: World Health Am J Health Promot. 2019;33(4):516-524. Organization; 2016. https://www.who.int/gender-equity- doi:10.1177/0890117118795987 rights/knowledge/advancing-the-right-to-health/en/. 11. Van den Brand FA, Dohmen LME,Van Schayck Accessed March 28, 2019. OCP, Nagelhout GE. ‘Secretly, it’s a competition’: A 23. Quote Investigator. https://quoteinvestigator.com/. qualitative study investigating what helped employees Accessed Jan 19, 2019. quit smoking during a workplace smoking cessation 24. Radwan GN, Loffredo CA, Aziz R, Abdel-Aziz N, Labib group training programme with incentives. BMJ Open. N. Implementation, barriers and challenges of smoke- 2018;8(11):e023917. doi:10.1136/bmjopen-2018-023917 free policies in hospitals in Egypt. BMC Research Notes. 12. Kava CM, Parker EA, Baquero B, Curry S, Gilbert PA, 2012;5(1). doi:10.1186/1756-0500-5-568 Sauder M, Sewell DK. A qualitative assessment of the 25. Honeycutt A, Bradley C, Khavjou O, Yarnoff B, Soler smoking policies and cessation activities at smaller R, Orenstein D. Simulated impacts and potential cost- workplaces. BMC Public Health. 2018;18(1):1094. effectiveness of Communities Putting Prevention doi:10.1186/s12889-018-6001-9 to Work: Tobacco control interventions in 21 US 13. Graff SK. There is No Constitutional Right to Smoke. communities, 2010-2020. Prev Med. 2019;120:100-106. 2nd ed. In: A Law Synopsis by the Tobacco Control Legal doi:10.1016/j.ypmed.2019.01.005 Consortium. Saint Paul, MN: Tobacco Control Legal 26. Warner KE, Smith RJ, Smith DG, Fries BE. Health and economic Consortium; 2008. https://www.publichealthlawcenter. implications of a work-site smoking-cessation program: a org/sites/default/files/resources/tclc-syn- simulation analysis. J Occup Environ Med. 1996;38(10):981- constitution-2008.pdf. Accessed March 25, 2019. 992. doi:10.1097/00043764-199610000-00008 14. United Nations. Universal Declaration of Human Rights. 27. Mache S, Vitzthum K, Groneberg DA, Harth V. Effects https://www.un.org/en/universal-declaration-human- of a multi-behavioral health promotion program at rights/. Accessed March 25, 2019. worksite on smoking patterns and quit behavior. Work.

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2019;62(4):543-551. doi:10.3233/WOR-192889 28. Halpern MT, Shikiar R, Rentz AM, Khan ZM. Impact of smoking status on workplace absenteeism and productivity. Tob Control. 2001;10(3):233-238. doi:10.1136/tc.10.3.233

CONFLICTS OF INTEREST The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

FUNDING There was no source of funding for this research.

PROVENANCE AND PEER REVIEW Not commissioned; externally peer reviewed.

Tob. Prev. Cessation 2020;6(February):9 https://doi.org/10.18332/tpc/115032 10